André Maya Caroline, Hammer Jürg
From the University Children's Hospital, Division of Respiratory and Critical Care Medicine, University of Basel, Basel, Switzerland.
Pediatr Emerg Care. 2019 Jun;35(6):e110-e112. doi: 10.1097/PEC.0000000000001407.
Reports on accidental intravenous epinephrine overdose in children are extremely rare, although medication errors in the management of pediatric anaphylaxis seem to be frequent. We report a case of a 12-year-old boy presenting with a long-lasting skin rash and dyspnea who was incorrectly diagnosed with early anaphylactic shock and was treated with 10-fold the recommended dose administered by the wrong route (intravenous instead of intramuscular). He reacted with acute loss of consciousness and acute cardiorespiratory failure due to arterial hypotension, ischemic heart failure, and severe pulmonary edema. He responded rapidly to mechanical ventilation, treatment with diuretics, and low-dose inotropes and recovered without sequelae. Despite this ultimately favorable outcome, we report this case to remind the scientific community that inadvertent and accidental epinephrine overdosing is probably an underrecognized event, which can result in potentially lethal complications. Heightening the awareness of the personnel, implementing safety precautions for the dosage and the route of administration, stocking of prefilled intramuscular dose syringes for emergency use in anaphylaxis and, ideally, introducing a standardized drug order form should reduce potential risks and facilitate proper and optimal treatment for all acutely ill children.
儿童意外静脉注射肾上腺素过量的报道极为罕见，尽管儿科过敏反应管理中的用药错误似乎很常见。我们报告一例12岁男孩，他出现长期皮疹和呼吸困难，被错误诊断为早期过敏性休克，并接受了推荐剂量10倍的药物，且给药途径错误（静脉注射而非肌肉注射）。他因动脉低血压、缺血性心力衰竭和严重肺水肿而出现急性意识丧失和急性心肺衰竭。他对机械通气、利尿剂治疗和小剂量血管活性药物反应迅速，且康复后无后遗症。尽管最终结果良好，但我们报告此病例是为提醒科学界，无意和意外的肾上腺素过量可能是一个未被充分认识的事件，可能导致潜在的致命并发症。提高人员意识、实施剂量和给药途径的安全预防措施、储备预填充肌肉注射剂量注射器以备过敏反应紧急使用，理想情况下，引入标准化的医嘱单，应可降低潜在风险，并为所有急病儿童提供适当和最佳的治疗。
